Reabilitação no Acidente Vascular Cerebral: do Hospital à Comunidade

The field of action for rehabilitation is that of making use of the patient's maximum functional capacity with the purpose of adapting to life in relation to the environment. Rehabilitation must commence immediately, although it may be in different forms from the acute phase to sequelae. It is considered appropriate to call the physiatrist as soon as the neurologic condition has stabilised. A list is made of the measures to be taken for rehabilitation in the acute phase and sequelae, and the composition of the rehabilitation team is described. In what concerns location, where to rehabilitate the patient? The group of ambulatory patients should have their rehabilitation as outpatients. Our experience with house calls is briefly described. The group of patients who cannot walk, those that present an eminently motor condition, with the possibility of being able to walk, should be with their families, with transport provided to health and rehabilitation centres. The second group, with the capacity of walking within a reasonable time, especially if with multiple associated problems such as impaired communication, should be hospitalised in a rehabilitation department. The third group consists of severely handicapped patients, for whom a solution must be found that provides life with a minimum of dignity in centres or homes. From among the measures to be introduced, we point out following: acquisition of transport for patients who must travel, as outpatients, to the department; providing family doctors with complete freedom to refer their patients to rehabilitation centres.

Cerebral aspergillosis due to Aspergillus fumigatus in AIDS patient: first culture - proven case reported in Brazil

Cerebral aspergillosis is a rare cause of brain expansive lesion in AIDS patients. We report the first culture-proven case of brain abscess due to Aspergillus fumigatus in a Brazilian AIDS patient. The patient, a 26 year-old male with human immunodeficiency virus (HIV) infection and history of pulmonary tuberculosis and cerebral toxoplasmosis, had fever, cough, dyspnea, and two episodes of seizures. The brain computerized tomography (CT) showed a bi-parietal and parasagittal hypodense lesion with peripheral enhancement, and significant mass effect. There was started anti-Toxoplasma treatment. Three weeks later, the patient presented mental confusion, and a new brain CT evidenced increase in the lesion. He underwent brain biopsy, draining 10 mL of purulent material. The direct mycological examination revealed septated and hyaline hyphae. There was started amphotericin B deoxycholate. The culture of the material demonstrated presence of the Aspergillus fumigatus. The following two months, the patient was submitted to three surgeries, with insertion of drainage catheter and administration of amphotericin B intralesional. Three months after hospital admission, his neurological condition suffered discrete changes. However, he died due to intrahospital pneumonia. Brain abscess caused by Aspergillus fumigatus must be considered in the differential diagnosis of the brain expansive lesions in AIDS patients in Brazil.

Septicemia caused by Paracoccidioides brasiliensis (Lutz, 1908) as the cause of death of an aids patient from Santos, São Paulo State, Brazil – a nonendemic area

The first case of Paracoccidioides brasiliensis in Santos (Brazil) leading to septicemia and death of an HIV-positive patient is reported here. The patient was a 34-year-old female that presented essential fever and was only diagnosed after death by positive blood culture. The authors underscore the atypical nature of the case, since the patient was a female at fertile age who was born and had always lived in Santos, which is a nonendemic area for this infection.

Pulmonary thromboembolism in AIDS patient with chronic venous insufficiency, pulmonary tuberculosis and breast cancer: a case report and pathophysiology review

Recent literature reports thrombotic episodes occurring in patients with HIV infection associated with other abnormalities including neoplasms and infections predisposing to a hypercoagulable state. We report a 47-year-old woman who developed pulmonary thromboembolism in association with HIV infection, pulmonary tuberculosis and breast cancer. She was treated with rifampin, isoniazid, pyrazinamide; heparin, phenprocoumon, zidovudine, lamivudine and efavirenz. Acid fast bacilli were visualized in a sputum smear and three months after, Mycobacterium tuberculosis was isolated from lymph node biopsy during a episode of immune reconstitution. The isolated mycobacteria showed sensitivity to all first-line drugs. HIV infection, breast cancer and pulmonary tuberculosis have several mechanisms that induce hypercoagulable state and can lead to thromboembolic complications. Pulmonary thromboembolism in this patient was a diagnostic challenge because of all the other severe diseases that she experienced at the same time.

Acute neuromuscular manifestations in a patient associated with ingesting octopus (Octopus sp.)

The authors report neuromuscular manifestations in a 45-year-old woman after consuming octopus meat (Octopus sp.). The patient presented malaise, paresthesias in perioral and extremity areas, intense muscular weakness and arterial hypotension, followed by severe itch and disseminated cutaneous rash. Gastrointestinal manifestations and fever were not observed, reducing the probability of alimentary poisoning. The presence of muscular and neurological symptoms suggests neurotoxin action, which could have been ingested by the victim from the octopus salivary glands or from an accumulation of toxins in the meat, or by an unknown mechanism. There is little known about toxins of the Octopus genus and this communication is important alert to the possibility of poisoning in humans that eat octopus and its differentiation from alimentary poisonings arising from incorrect conservation of seafood.

Adverse Effect of Alcohol Drinking: The Role of Oxidative Stress

Atualmente, o álcool tem um papel importante na saúde pública e surge como um dos principais problemas sociais no mundo, dado que é a droga mais viciante aceite em encontros sociais. Provavelmente, por essa razão, os riscos do consumo abusivo do álcool são subestimados pelos jovens, mulheres grávidas e idosos. O álcool, quando ingerido em altas proporções, pode afetar todos os órgãos e desencadear inúmeras doenças, tais como a doença cardíaca coronariana, doença neurodegenerativa, as doenças crónicas e câncer. O álcool afeta ainda o estado psicológico, induzindo a violência, o estado antissocial e situações de risco de comportamentos. Por estas razões, o álcool tornou-se um foco principal da investigação, avaliando os seus efeitos sobre o corpo humano. Nesta pesquisa, foram suscitadas amostras de sangue de um grupo de pacientes em tratamento psicológico e/ou farmacêutico que serão analisadas com quatro métodos: Teste de Radicais Livres do Oxigénio (FORT), Defesa contra Radicais Livres do Oxigénio (FORD), cromatografia gasosa (GC) e cromatografia líquida de alta pressão (HPLC). Ambos os métodos FORT e FORD avaliam o stress oxidativo pela quantificação de radicais livres e a capacidade de antioxidantes em eliminar esses radicais livres, respetivamente. O stress oxidativo é o efeito do excesso de consumo de álcool, que é reduzido pela capacidade de ação dos antioxidantes. A boa reprodutibilidade, precisão e exatidão de ambos os métodos indicam que estes podem ser aplicados em rápidos diagnósticos. Para o método FORT e considerando o início do tratamento, os pacientes alcoólicos apresentaram uma média de 3,59±1.01mmol/LH2O2 e o grupo de controlo uma média de 1,42±0.53mmol/LH2O2, o que mostra uma diferença significativa entre os dois grupos (P=0,0006). Para o método FORD, pacientes alcoólicos apresentam uma média de 1,07±0.53mmol/LH2O2 e o grupo de controlo, uma média de 2,81±0.46mmol/LH2O2, mostrando também uma média significativa (P=0,0075). Após 15 dias de tratamento observou-se que há uma diferença entre os dois grupos de pacientes alcoólicos, mas não há nenhum melhoramento em relação ao grupo de pacientes em tratamento. No método FORT os grupos mostram uma diferença significativa (P=0,0073), tendo os pacientes sem tratamento farmacêutico melhores resultados (2.37±0.44mmol/LH2O2) do que os pacientes com tratamento (3.72±1,04mmol/LH2O2). O oposto ocorre no método FORD, os pacientes em tratamento farmacêutico presentam melhores resultados (1.16±0.65mmol/LH2O2) do que o outro grupo (0.75±0.22mmol/LH2O2), não sendo, no entanto, uma diferença significativa entre os dois grupos (P=0.16). Os resultados obtidos para a concentração de MDA pelo método de HPLC mostraram que o grupo de controlo tem valores mais baixos do que os pacientes alcoólicos, embora a diferença não seja muito significativa (P = 0,084), mas é ainda elevada. Além disso, os dois grupos de pacientes não apresentaram uma diferença significativa entre os seus resultados no início (P=0,77) e no fim (P=0,79) do tratamento. De acrescentar ainda que, os resultados da concentração de álcool no sangue determinados pelo método de CG mostraram que só alguns pacientes sem tratamento consumiram álcool durante o período de tratamento, o que influencia negativamente a conclusão sobre o efeito do tratamento. Contudo, outros fatores externos podem ainda influenciar os resultados finais, tais como o estado nutricional e estado psicológico dos pacientes, se o paciente continua a beber durante o tempo de tratamento ou até mesmo se o paciente é exposto a outros tipos de substâncias nocivas. Existe ainda a possibilidade de o tempo de aplicação do tratamento não ser suficiente para apresentar um efeito positivo em relação ao stress oxidativo e este é um outro fator que contribui para a impossibilidade de confirmar sobre o efeito, quer seja positivo ou negativo, do tratamento antioxidante.

Bacillary Angiomatosis by Bartonella Quintana in an HIV-Infected Patient

Bacillary angiomatosis and bacillary peliosis are opportunistic infections caused by Bartonella henselae and Bartonella quintana, which occur in patients with late-stage infection. We report a case of bacillary angiomatosis in an HIV-infected patient with skin, bone, and probably liver involvement, The identification of the agent (B quintana ) was done by polymerase chain reaction in the skin specimen. The patient had complete regression of all lesions after a 6-month regimen of oral erythromycin.

Disseminated nocardiosis with psoas abscess in a patient with AIDS: first reported case

Psoas muscle abscess is an uncommon infection that have been diagnosed increasingly in the last years. We present a case of a patient with advanced human immunodeficiency virus infection who developed a disseminated infection due to Nocardia asteroides sensu stricto type VI with psoas abscess. To our knowledge no other cases of Nocardia psoas abscess in the setting of HIV infection have been reported in the literature.

Leprosy and Kaposi Sarcoma Presenting as an Immune Reconstitution Inflammatory Syndrome in a Patient with AIDS

The simultaneous presence of infectious organisms within cutaneous lesions of Kaposi sarcoma in persons with AIDS has been demonstrated. We describe a patient with concurrent leprosy and Kaposi sarcoma presenting as an immune reconstitution inflammatory syndrome in the setting of AIDS.

Sirolimus-Induced Drug Fever in a Renal Transplant Patient: a Case Report

Herein we have described the case of a male renal transplant recipient who developed drug fever apparently related to sirolimus. He had been stable under an immunosuppressive regimen of tacrolimus and mycophenolate mofetil, but developed acute cellular rejection at 5 years after transplantation due to noncompliance. Renal biopsy showed marked interstitial fibrosis, and immunosuppression was switched from mycophenolate to sirolimus, maintaining low tacrolimus levels. One month later he was admitted to our hospital for investigation of intermittently high fever, fatigue, myalgias, and diarrhea. Physical examination was unremarkable and drug levels were not increased. Lactic dehydrogenase and C-reactive protein were increased. The blood cell count and chest radiographic findings were normal. After extensive cultures, he was started on broad-spectrum antibiotics. Inflammatory markers and fever worsened, but diarrhea resolved. All serologic and imaging tests excluded infection, immune-mediated diseases, and malignancy. After 12 days antibiotics were stopped as no clinical improvement was achieved. Drug fever was suspected; sirolimus was replaced by mycophenolate mofetil. Fever and other symptoms disappeared after 24 hours; inflammatory markers normalized in a few days. After 1 month the patient was in good health with stable renal function. Although infrequent, the recognition of drug fever as a potential side effect of sirolimus may avoid unnecessary invasive diagnostic procedures. Nevertheless, exclusion of other common causes of fever is essential.

Schistosomiasis haematobia: histopathological course determined by cystoscopy in a patient in whom praziquantel treatment failed

Schistosomiasis haematobia or urinary schistosomiasis is one of the main public health problems in Africa and the Middle East. A single dose of 40 mg praziquantel per kg body weight continues to be the treatment of choice for this infection. The aims of this follow-up were to study the post-treatment course of a patient infected with S. haematobium and not submitted to re-exposure, and to identify complications of the disease and/or therapeutic failure after praziquantel treatment by histopathological analysis. Treatments were repeated under medical supervision to ensure the correct use of the drug. In view of the suspicion of lesions in cystoscopy, the patient was submitted to bladder biopsy. The histopathological characteristics observed in biopsies obtained, after each treatment, indicated viability of parasite eggs and activity of granulomas.

Endobronchial leiomyoma: an unusual non-defining neoplasm in a patient with AIDS

Smooth muscle neoplasms are more frequent in human immunodeficiency infected children than in HIV seropositive adults. Endobronchial leiomyoma is a rare benign tumor in HIV infected adult patients. Epstein-Barr virus (EBV) has been implicated in the pathogenesis of these tumors. Here we describe an adult patient with HIV infection with atelectasis of the left upper pulmonary lobe as the first clinical expression of an intrabronchial leiomyoma. In this case, we can not show the association with EBV. Our report suggests that smooth muscle tumors as leiomyoma should be included in the differential diagnosis of endobronchial masses in AIDS patients.